Quality of life in individuals with patellofemoral pain: A systematic review including meta-analysis

doi:10.1016/j.ptsp.2018.06.006

Physical Therapy in Sport

Volume 33, September 2018, Pages 96-108

https://doi.org/10.1016/j.ptsp.2018.06.006 Get rights and content

Highlights

•
People with patellofemoral pain have impaired quality of life.
•
Quality of life is worse than the general population.
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Quality of life is worse than pain-free people.
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Physical therapy may improve quality of life.

Abstract

Objective

The aim of this systematic review is to describe QoL in individuals with PFP, and determine the impact of PFP interventions on QoL.

Methods

Five databases were searched for studies reporting QoL in individuals with PFP, with mean age under 50 years. Data were pooled based on QoL tool (e.g. Knee Injury and Osteoarthritis Outcome Score [KOOS] QoL subscale, Short-Form 36 item health survey [SF-36]) using random-effects models, or through narrative synthesis where inadequate data were available.

Results

Individuals with PFP, had worse KOOS-QOL scores (pooled mean: 47[95% CI: 34 to 61] and health-related QoL (pooled SF-36 PCS and MCS: 47[95% CI: 41 to 53] and 54[95% CI: 47 to 62], respectively) compared with pain-free controls and population norms. Physical interventions were associated with improvements in knee- and health-related QoL in individuals with PFP in repeated measures studies. However, the effect of physical interventions compared to a control treatment was conflicting.

Conclusion

Individuals with PFP aged under 50 years, have markedly reduced knee- and health-related QoL compared to pain-free controls and population norms. Knee- and health-related QoL may improve following intervention, but it is unclear if these improvements are greater than that which occur in a control group.

Introduction

Patellofemoral pain (PFP) is a common disorder of the knee (Van Middelkoop, Van Linschoten, Berger, Koes, & Bierma-Zeinstra, 2008), prevalent in adolescent (Mølgaard, Rathleff, & Simonsen, 2011) and adult populations (Wood, Muller, & Peat, 2011), and particularly prevalent in physically active individuals (Powers, 2003). PFP is a chronic, painful condition predominantly of insidious onset, which often persists despite provision of evidence-based treatments (Rathleff, Olesen, Roos, Rasmussen, & Rathleff, 2013). Research suggests that 57% of individuals with PFP may experience persistent symptoms and unfavourable outcomes 5–8 years after enrolment in a clinical trial (Lankhorst et al., 2015). Moreover, symptom severity may remain unchanged or progress in 50% of affected individuals (Blond & Hansen, 1998), often restricting an individual's participation in physical activity (Rathleff, Rathleff, Olesen, Rasmussen, Roos, 2016) and potentially reducing quality of life (QoL).

Health-related QoL is a multi-dimensional concept, encompassing physical, psychological and social aspects associated with a disease or its treatment (Guyatt, Feeny, & Patrick, 1993). Disease-specific and generic health-related QoL measures are used to evaluate patient experience of a musculoskeletal condition and the benefit of therapeutic interventions (Sanders, Egger, Donovan, Tallon, & Frankel, 1998). The patients' perspective and experience should be paramount when evaluating the impact of a condition or the efficacy of an intervention (Roos, Roos, Lohmander, Ekdahl, & Beynnon, 1998). The use of QoL instruments recognizes that patient perceptions do not always match with knee pathology (Tornbjerg et al., 2016) or findings from a clinical examination of the knee (Iversen, Price, von Heideken, Harvey, & Wang, 2016). Although rarely the primary outcome of interest, knee- and health-related QoL outcomes have been reported in a number of studies investigating individuals with PFP, and have been used to evaluate intervention efficacy for this condition. Synthesis of this evidence will provide a better understanding of the impact of PFP and the influence of specific treatment strategies on QoL.

This systematic review aims to: (i) describe QoL in individuals with PFP compared to pain-free controls and population norms; (2) evaluate whether intervention is associated with improved QoL in individuals with PFP; and (3) identify factors associated with QoL in individuals with PFP.

Section snippets

Methods

This systematic review followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009), with the protocol prospectively registered on PROSPERO (http://www.crd.york.ac.uk/PROSPERO/; CRD 42016026307, 12 April 2016). There were no peer-reviewed literature reviews of this topic at the time.

Search strategy, methodological quality, and risk of bias

The comprehensive search strategy identified 1573 titles, with 1304 titles and abstracts evaluated after removal of duplicates. The full-text of 93 articles were retrieved and assessed for eligibility. Two additional papers were identified by citation tracking, and four were identified in an updated search performed prior to final data analysis using the same search strategy, in January 2017. Twenty-one studies met the selection criteria (Fig. 1).

Thirteen authors (for 15 studies) were contacted

QoL in individuals with PFP

This systematic review revealed that individuals with PFP had substantially worse knee- and health-related QoL relative to pain-free controls (KOOS-QoL mean difference: 51, SF-36 domains mean difference range: 16–47) and population norms (KOOS-QoL mean difference: 37, SF-36 domains mean difference range: 14–36). Impairments in knee- and health-related QoL, were highlighted by the fact that pooled PFP mean 95% CI upper limits were all lower than the 95% CI lower limits for pain-free and

Conclusion

Individuals with PFP aged under 50 years, have impaired knee- and health-related QoL compared to the general population and pain-free individuals. Based on current evidence, including a paucity of high quality randomized controlled trials, it is unclear whether common interventions provided to individuals with PFP have any beneficial effect on knee- and health-related QoL when compared to a control group. Developing treatments to target knee-related and health-related QoL in individuals with

Conflicts of interest

We affirm that we have no financial affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript, except as disclosed in an attachment and cited in the manuscript.

Funding

HFH is supported by a National Health and Medical Research Council Project Grant (GNT1106852).

Ethical approval

Not applicable.

PROSPERO registration number

CRD42016026307.

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Clinic- and laboratory-based measures of postural control in patellofemoral pain: A systematic review with meta-analysis and evidence gap map
2024, Gait and Posture
Patellofemoral pain (PFP) is a prevalent musculoskeletal disorder associated with functional impairments. Although postural control is commonly assessed in people with PFP, there are inconsistent results regarding potential postural control deficits in this population.
This review aims to evaluate whether postural control is impaired in people with patellofemoral pain (PFP) and the effectiveness of interventions on postural control measures.
We searched six databases from their inception to May 5, 2023. We included studies assessing clinic- or laboratory-based postural control measures in people with PFP compared to pain-free controls, and intervention studies with PFP populations. We assessed risk of bias using the Joanna Briggs Institute critical appraisal checklists and the Cochrane Risk of Bias 2 tool. We assessed the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. We used random-effects meta-analyses considering subgroups based on type of task, measure, and intervention.
Fifty-three studies were included. Very low certainty evidence indicated that people with PFP have shorter anterior (SMD = 0.53, 95 %CI:0.16,0.90), posteromedial (SMD = 0.54, 95 %CI:0.04,1.03) and posterolateral (SMD = 0.59, 95 %CI:0.11,1.07) reach distance, and worse composite score (SMD = 0.46, 95 %CI:0.22,0.70). Very low to moderate certainty evidence indicated that people with PFP have worse anterior-posterior and overall stability indexes during single-leg stance (SMD = −0.71, 95 %CI:−1.29,−0.14; SMD = −0.63, 95 %CI:−0.94,−0.32) and overall stability index during double-leg stance (SMD = −0.39, 95 %CI:−0.78,−0.00), but no differences in center of pressure area during stair ascent (SMD = 0.32, 95 %CI:−2.72, 3.36). Low certainty evidence indicated that kinesio taping improved anterior reach distance (SMD = −0.49, 95 %CI:−0.89,−0.09), while no significant differences were observed between pre- and post-intervention outcomes for conventional rehabilitation and rigid taping.
Clinicians should use clinic- (star excursion or Y-balance tests) and laboratory-based (stability indexes) measures to identify impairments of postural control in people with PFP. Low certainty of evidence suggests short-term improvement in postural control with kinesio taping.
Influence of self-perceived disability on squatting kinematics in individuals with patellofemoral pain
2023, Clinical Biomechanics
Individuals with patellofemoral pain have a heterogeneous presentation of symptoms during functional tasks; however, biomechanical data often negates self-reported disability. The single leg squat is common in patellofemoral pain literature but may not be a pain provoking task for all individuals. Therefore, our study examined the influence of self-perceived squatting disability in individuals with patellofemoral pain on lower extremity squatting kinematics.
We analyzed two-dimensional hip frontal plane projection angle, knee frontal plane projection angle, lateral trunk movement, and pelvic drop in 100 participants, 82 with patellofemoral pain and 18 pain-free controls. Participants with patellofemoral pain were dichotomized based on the level of disability reported during squatting on the anterior knee pain scale. An analysis of variance with post hoc testing was used to compare differences in lower extremity and trunk kinematics between groups, p < 0.05.
Participants who reported only being able to squat with partial weight bearing had greater hip frontal plane projection angles than those who reported squatting painful each time (p = 0.017). The partial weight bearing group had greater knee frontal plane projection angles compared those who reported pain with repeated squatting and the pain-free group, (p < 0.034). We found no significant differences in lateral trunk motion or pelvic drop between groups.
Individuals with patellofemoral pain who self-reported worse squatting disability had greater hip and knee frontal plane motion compared to individuals with less disability and pain-free controls. Clinicians and researchers should consider specific pain provoking tasks when evaluating and treating patients with patellofemoral pain.
Lower extremity muscle volume in females with patellofemoral pain and its relationships to hip and knee torque: A cross-sectional study
2023, Physical Therapy in Sport
Compare lower extremity muscle volume in females with patellofemoral pain (PFP) to a cohort of pain-free females and investigate the relationship between thigh and hip muscle volume and torque.
Cross-sectional.
Twenty-one females, 13 with PFP and 8 pain-free controls.
We quantified normalized lower extremity muscle volume (cm³/kg*m) via magnetic resonance imaging and isometric hip and thigh torque (Nm/kg) via a multimodal dynamometer.
Versus pain-free individuals, females with PFP had smaller muscle volume of the anterior hip (P < 0.019; d = 0.97–2.42), deep external rotators (P < 0.006; d = 1.0–3.93), hamstrings (P < 0.009; d = 1.09–2.12), rectus femoris (P < 0.001; d = 1.79), and vastus intermedius (P < 0.001; d = 1.88). There was no difference in muscle volume of the gluteus maximus (P = 0.311; d = 0.22), gluteus medius (P = 0.087; d = 0.87), vastus lateralis (P = 0.22; d = 0.39), and vastus medialis (P = 0.47; d = 0.04). Gluteus maximus volume was moderately correlated to hip abduction torque (r = 0.60; P = 0.03). Vasti muscles and semitendinosus volume were moderately correlated to knee extension (r = 0.57–0.69; P < 0.05) and flexion (r = 0.66; P = 0.01) torque, respectively.
Females with PFP present with lesser thigh and hip muscle volumes, with variability in volumetric profiles across participants. Lower extremity knee extension and hip abduction strength are moderately associated with the vasti and gluteus maximus muscle volume, respectively.
Overweight and obesity in young adults with patellofemoral pain: Impact on functional capacity and strength
2023, Journal of Sport and Health Science
This study aimed to (a) investigate the proportion of overweight/obesity in a cohort of young adults with patellofemoral pain (PFP) and (b) explore the association of body mass index (BMI), body fat, and lean mass with functional capacity and hip and knee strength in people with PFP.
We included a mixed-sex sample of young adults (18−35 years old) with PFP (n = 100). Measurements for BMI, percentage of body fat, and lean mass (assessed by bioelectrical impedance) were obtained. Functional capacity was assessed by the Anterior Knee Pain Scale, plank test, and single-leg hop test. Strength of the knee extensors, knee flexors, and hip abductors was evaluated isometrically using an isokinetic dynamometer. The proportion of overweight/obesity was calculated based on BMI. The association between BMI, body fat, and lean mass and functional capacity and strength was investigated using partial correlations, followed by hierarchical regression analysis, adjusted for covariates (sex, bilateral pain, and current pain level).
A total of 38% of our cohort had their BMI categorized as overweight/obese. Higher BMI was associated with poor functional capacity (ΔR² = 0.06−0.12, p ≤ 0.001) and with knee flexion strength only (ΔR² = 0.04, p = 0.030). Higher body fat was associated with poor functional capacity (ΔR² = 0.05−0.15, p ≤ 0.015) and reduced strength (ΔR² = 0.15−0.23, p < 0.001). Lower lean mass was associated with poor functional capacity (ΔR² = 0.04−0.13, p ≤ 0.032) and reduced strength (ΔR² = 0.29− 0.31, p < 0.001).
BMI, body fat, and lean mass should be considered in the assessment and management of young people with PFP because it may be detrimental to function and strength.
There is more to the knee joint than just the quadriceps: A systematic review with meta-analysis and evidence gap map of hamstring strength, flexibility, and morphology in individuals with gradual-onset knee disorders
2023, Journal of Sport and Health Science
Impairments in hamstring strength, flexibility, and morphology have been associated with altered knee biomechanics, pain, and function. Determining the presence of these impairments in individuals with gradual-onset knee disorders is important and may indicate targets for assessment and rehabilitation. This systematic review aimed to synthesize the literature to determine the presence of impairments in hamstring strength, flexibility, and morphology in individuals with gradual-onset knee disorders.
Five databases ((MEDLINE, Embase, CINAHL, SPORTDiscus, and Web of Science) were searched from inception to September 2022. Only studies comparing hamstring outcomes (e.g., strength, flexibility, and/or morphology) between individuals with gradual-onset knee disorders and their unaffected limbs or pain-free controls were included. Meta-analyses for each knee disorder were performed. Outcome-level certainty was assessed using the Grading of Recommendations Assessment, Development, and Evaluation, and evidence gap maps were created.
Seventy-nine studies across 4 different gradual-onset knee disorders (i.e., knee osteoarthritis (OA), patellofemoral pain (PFP), chondromalacia patellae, and patellar tendinopathy) were included. Individuals with knee OA presented with reduced hamstring strength compared to pain-free controls during isometric (standard mean difference (SMD) = –0.76, 95% confidence interval (95%CI) : –1.32 to –0.21) and concentric contractions (SMD = –0.97, 95%CI : –1.49 to –0.45). Individuals with PFP presented with reduced hamstring strength compared to pain-free controls during isometric (SMD = –0.48, 95%CI : –0.82 to –0.14), concentric (SMD = –1.07, 95%CI : –2.08 to –0.06), and eccentric contractions (SMD = –0.59, 95%CI : –0.97 to –0.21). No differences were observed in individuals with patellar tendinopathy. Individuals with PFP presented with reduced hamstring flexibility when compared to pain-free controls (SMD = –0.76, 95%CI : –1.15 to –0.36). Evidence gap maps identified insufficient evidence for chondromalacia patellae and hamstring morphology across all gradual-onset knee disorders.
Our findings suggest that assessing and targeting impairments in hamstring strength and flexibility during rehabilitation may be recommended for individuals with knee OA or PFP.
Exacerbating patellofemoral pain alters trunk and lower limb coordination patterns and hip-knee mechanics
2022, Journal of Biomechanics
Citation Excerpt :
The characteristic anterior knee pain is typically exacerbated by activities that have higher loading demands on the patellofemoral joint (PFJ) such as stair negotiation, stepping down, and running (Bazett-Jones et al., 2013; Briani et al., 2018). PFP also negatively affects people’s quality of life (Coburn et al., 2018), functional performance (Nunes et al., 2019), and psychological well-being (Priore et al., 2019). Elevated PFJ loading has been linked with PFP (Powers et al., 2017) and increases in PFP symptoms (Atkins et al., 2018).
The exacerbation of patellofemoral pain (PFP) may lead to compensatory trunk and lower limb movement patterns in order to minimize patellofemoral joint loading. However, joint kinematics are often analysed in isolation, which limits the understanding of how the underlying segments were coordinated to produce limb postures and distribute load across the limb. In this study we used a dynamical systems approach to investigate how women with PFP coordinate trunk, hip, and knee motion and distribute hip-knee moment demands following symptom exacerbation. Coordination patterns and coordination variability of the trunk, hip, and knee from 61 women with PFP were obtained during stair descent, ascent, and step down tasks, before and after a pain exacerbation protocol. Hip-knee extensor moment impulse ratio was also calculated. Following the exacerbation of PFP, women utilized knee dominant coordination patterns less often (p = 0.039–0.027; d = 0.51–0.53), while coordination patterns with the trunk leaning forward were utilized more during stair negotiation (p = 0.043-<0.001; d = 0.52–0.96). Although no significant differences in hip-knee coordination patterns were found, there was an increase in the hip-knee impulse ratio during stair negotiation (p = 0.014-<0.001; d = 0.27–0.36). These findings seem to display a movement strategy utilized by women with PFP in order to distribute more load to the hip joint and less to the knee joint, possibly in an attempt to avoid/manage pain.

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Literature ReviewQuality of life in individuals with patellofemoral pain: A systematic review including meta-analysis

Highlights

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Search strategy, methodological quality, and risk of bias

QoL in individuals with PFP

Conclusion

Conflicts of interest

Funding

Ethical approval

PROSPERO registration number

The Knee.

PM&R.

Osteoarthritis and Cartilage

The Knee

Clinical Biomechanics

Manual Therapy

PM&R.

Journal of Clinical Epidemiology

International quality of life assessment (IQOLA) project

Quality of Life Research

The effect of isokinetic exercise on symptoms, functional status and EMG activation onset time of the vastus medialis oblique and vastus lateralis in female patients with patellofemoral pain syndrome

Isokinetics and Exercise Science

Health-related quality of life associated with chronic conditions in eight countries: Results from the International Quality of Life Assessment (IQOLA) Project

Quality of Life Research

The validity and reliability of the Thai version of the Kujala score for patients with patellofemoral pain syndrome

Disability & Rehabilitation

A study on the effects of patella taping on pain, quality of life and radiographic findings in patients with patellofemoral pain syndrome

Journal of Babol University of Medical Sciences

Patellofemoral pain syndrome in athletes: A 5.7-year retrospective follow-up study of 250 athletes

Acta Orthopaedica Belgica

Introduction to meta-analysis

Normative values for the KOOS and WOMAC in a young athletic population: History of knee ligament injury is associated with lower scores

The American Journal of Sports Medicine

Gender differences in health-related quality-of-life are partly explained by sociodemographic and socioeconomic variation between adult men and women in the US: Evidence from four US nationally representative data sets

Quality of Life Research

Chinese translation and validation of the Kujala scale for patients with patellofemoral pain

Disability & Rehabilitation

Physical therapy for patellofemoral pain: A randomized, double-blinded, placebo-controlled trial

The American Journal of Sports Medicine

The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions

Journal of Epidemiology & Community Health

Effect of eccentric isotonic quadriceps muscle exercises on patellofemoral pain Syndrome: An exploratory pilot study

Asian Journal of Sports Medicine

Health-related quality of life after anterior cruciate ligament reconstruction: A systematic review

The American Journal of Sports Medicine

Measuring health-related quality of life

Annals of Internal Medicine

The prevalence of radiographic and MRI-defined patellofemoral osteoarthritis and structural pathology: A systematic review and meta-analysis

British Journal of Sports Medicine

Exercise for treating patellofemoral pain syndrome

The Cochrane Library

The Cochrane Collaboration's tool for assessing risk of bias in randomised trials

BMJ British Medical Journal

Normative SF-36 values in competing NCAA intercollegiate athletes differ from values in the general population

The Journal of Bone & Joint Surgery

Physical examination findings and their relationship with performance-based function in adults with knee osteoarthritis

BMC Musculoskeletal Disorders

High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003–2004 to 2007–2008: Time for an anterior cruciate ligament register by scandinavian model?

Scandinavian Journal of Medicine & Science in Sports

Measuring health-related quality of life in adolescents and young adults: Swedish normative data for the SF-36 and the HADS, and the influence of age, gender, and method of administration

Health and Quality of Life Outcomes

Comparison of efficiency of Kinesio® taping and electrical stimulation in patients with patellofemoral pain syndrome

Acta Orthopaedica et Traumatologica Turcica

Literature Review
Quality of life in individuals with patellofemoral pain: A systematic review including meta-analysis

Comparison of efficiency of Kinesio^® taping and electrical stimulation in patients with patellofemoral pain syndrome